Is OMI an ECG Diagnosis?
Written by Jesse McLaren A 70 year old with prior MIs and stents to LAD and RCA presented to the emergency
department with 2 weeks of increasing exertional chest pain radiating to the
left arm, associated with nausea. The pain recurred at rest 90 minutes prior to
presentation, felt like the patient ’s prior MIs, and was not relieved by 6
sprays of nitro. Paramedics provided another 3 sprays of nitro, and 6mg of
morphine, which reduced but did not resolve the pain. What do you think of the ECG, and does it
matter?There ’s normal sinus rhythm, LAFB, old anterior Q waves,
and no diagnostic sign of OMI. I sent th...
Source: Dr. Smith's ECG Blog - April 18, 2024 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
ECG in LMCA Stenosis
ECG in a person with persistent anginal pain for the past several hours showing significant ST segment depression anterolateral leads along with sinus tachycardia. ST segment elevation is noted in aVR. Such a pattern is consistent with significant left main coronary artery stenosis.
Clinical evaluation and X-Ray chest showed features of pulmonary edema. Angiography done after initial stabilization showed severe stenosis of distal left main coronary artery. In addition, there were multiple lesions in all three vessels, making a standard indication for an urgent coronary artery bypass grafting.
A similar ECG pattern can also...
Source: Cardiophile MD - April 13, 2024 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
A 29 year old male with chest pain, ST Elevation, and very elevated troponin T
By Magnus NossenThis ECG is from a young man with no risk factors for CAD, he presented with chest pain. How would you assess this ECG? How confident are you in your assessment? What is your next step? Note: lead format is CabreraI was sent this ECG in real time. The patient is a young adult male with chest pain. The chest pain was described as pressure like and radiation to both arms and the jaw. Symptoms were on and off. The pain was worse in the night and better when moving. The patient sought medical attention when the pain recurred for a second straight night accompanied by arm numbness as well as radiating pain. The ...
Source: Dr. Smith's ECG Blog - April 9, 2024 Category: Cardiology Authors: Magnus Nossen Source Type: blogs
A young woman with chest pain, cath lab activated
This case came from a friend whose sister was the patient. She knew I was interested in ECGs, so she took a photo of this one.A young woman presented with acute chest pain.This was her presenting ECG:What do you think?This is clearly Brugada phenotype. There is downsloping ST Elevation in V1 and V2. To an experienced interpreter, it is clearly not due to OMI. And it is clearly Brugada phenotype.The conventional algorithm did not interpret Brugada. In fact, it read: ** **ACUTE MI / STEMI ** **The physicians caring for the patient activated the cath lab for " STEMI " .The interventionalist and cath tea...
Source: Dr. Smith's ECG Blog - April 6, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs
Ventricular Fibrillation, ICD, LBBB, QRS of 210 ms, Positive Smith Modified Sgarbossa Criteria, and Pacemaker-Mediated Tachycardia
An elderly man collapsed. There was no bystander CPR. Medics found him in ventricular fibrillation. He was defibrillated, but they also noticed that he was being internally defibrillated and then found that he had an implantable ICD.He was unidentified and there were no records availableAfter 7 shocks, he was successfully defibrillated and brought to the ED.Bedside ED ultrasound showed exceedingly poor global LV function, and no B lines.Here is the initial ED ECG. What do you think?Rhythm: Residents asked me why it is not VT. If you use calipers (or equvalent), it is clear that the rhythm...
Source: Dr. Smith's ECG Blog - April 2, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs
Ebstein ’ s Anomaly of Tricuspid Valve
Transcript of the video: Ebstein’s Anomaly is one of the cyanotic congenital heart disease in which survival to adult life is common. In Ebstein’s anomaly, there is downward or apical displacement of posterior and septal tricuspid leaflets. The anterior leaflet is not displaced, but is elongated to meet the other leaflets, so that when it closes, a loud sound, tricuspid sound, is produced, which is called as the sail sound. Ebstein’s anomaly may be associated with atrial septal defect or a patent foramen ovale, in about 50% of cases. The cyanosis in Ebstein’s anomaly, is usually not due to pulmonary...
Source: Cardiophile MD - March 30, 2024 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
Pediatric Exercise Testing
Discussion on pediatric exercise testing.
Pediatric exercise testing may be used for evaluation of various disorders of cardiac rhythm rather than for inducible ischemia as in adults.
In a child with suspected sinus node dysfunction, chronotropic incompetence from sinus node dysfunction can be assessed by exercise testing.
Evaluation of escape rates and ventricular ectopy with exercise in complete heart block is an important aspect in the evaluation of congenital complete heart block.
ECG showing congenital complete heart block with ventricular rate of 47/min and atrial rate of 63/min.
In stage I of Bruce protocol, the atr...
Source: Cardiophile MD - March 25, 2024 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
Palpitations and presyncope in a 40-something
Discussion: Putting all of the information together this patient is most likely suffering from arrhythmogenic cardiomyopathy (AC) better known as ARVC. The medical hx is typical, with sudden onset tachydysrhythmia during physical exertion. It is not uncommon for the initial presentation to be sudden cardiac death (SCD). In fact it is one of the leading causes of SCD in people age less than 40 years. Thus it is very important to identify this disorder. AC is a disease in which myocardium is replaced by fibrofatty tissue. This usually and predominantly affects the RV free wall and apical regions, but it can affect the left v...
Source: Dr. Smith's ECG Blog - March 24, 2024 Category: Cardiology Authors: Magnus Nossen Source Type: blogs
Three patients with chest pain and “normal” ECGs: which had OMI? Which were normal? And how did the Queen of Hearts perform?
This study had such low risk patients that not a single patient was ultimately diagnosed with ACS. It is well known that NOMI usually has a normal ECG or nonspecific ECG. The fact that not a single one of these patients had ACS shows that the population studied could not possibly support their conclusion. It should never have been published.According to this data a triage ECG labeled ‘normal’ rules out the possibility of acute coronary occlusion.This is obviously unreliable
data, as Dr. Smith ’s Blog has published51
cases of OMI with ECGs labeled ‘normal’, 35 of which were identified by the
Queen ...
Source: Dr. Smith's ECG Blog - March 14, 2024 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
A man in his 40s with 3 days of stuttering chest pain
Written byWilly FrickA man in his early 40s with BMI 36, hypertension, and a 30 pack-year smoking history presented with three days of chest pain. It started while he was at rest after finishing a workout. He described it as a mild intensity, nagging pain on the right side of his chest with nausea and dyspnea. It woke him the next day and radiated into his back. He was only able to sleep while sitting in a chair. He went to urgent care and had an ECG (not available) which was interpreted as normal, and was sent home. His pain returned, and he went back to the urgent care but was sent to the ER. His ECG is shown:What do you...
Source: Dr. Smith's ECG Blog - March 13, 2024 Category: Cardiology Authors: Willy Frick Source Type: blogs
Acute chest pain and ST Elevation. CT done to look for aortic dissection.....
Written byWilly FrickA 67 year old man with a history of hypertension presented with three days of chest pain radiating to his back. He had associated nausea, vomiting, and dyspnea.What do you think?This ECG together with these symptoms is certainly concerning for OMI, but the ECG is not fully diagnostic, and another consideration could be acute pericarditis. Mistaking OMI for pericarditis is a much more harmful error than the converse. Still, in the interest of studying the ECG, here are some findings that could support pericarditis:Absence of large T-waves (flat ST segments)Absence of any STD in aVL (which is s...
Source: Dr. Smith's ECG Blog - March 9, 2024 Category: Cardiology Authors: Willy Frick Source Type: blogs
Young man with Gunshot wound to right chest with hemorrhagic shock, but bullet path not near heart
A young man presented with a gunshot wound to the right chest, with hemo-pneumothorax and hemorrhagic shock.He got a chest tube and intubation and massive transfusion and stabilized.CT of chest showed the bullet path through his right lung but nowhere near his heart.But he did get an EKG:What is this? There were times when it would be usurped by sinus tachycardia, then return to this rhythm.There is a wide complex. It is irregular. It is not fast (cannot be VT). There is no atrial activity to suggest atrial fibrillation. There are whatcould be interpreted as delta wavesif, and only if, th...
Source: Dr. Smith's ECG Blog - March 7, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs
Young man with Gunshot wound to right chest with hemorrhagic shock, but bullet path not near heart. A case of irregular accelerated idioventricular rhythm (AIVR)
A young man presented with a gunshot wound to the right chest, with hemo-pneumothorax and hemorrhagic shock.He got a chest tube and intubation and massive transfusion and stabilized.CT of chest showed the bullet path through his right lung but nowhere near his heart.But he did get an EKG:What is this? There were times when it would be usurped by sinus tachycardia, then return to this rhythm.There is a wide complex. It is irregular. It is not fast (cannot be VT). There is no atrial activity to suggest atrial fibrillation. There are whatcould be interpreted as delta wavesif, and only if, th...
Source: Dr. Smith's ECG Blog - March 7, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs
When the conventional algorithm diagnoses the ECG as COMPLETELY NORMAL, but there is in fact OMI, what does the Queen of Hearts PM Cardio AI app say? (with 10 case examples)
Conclusions Need Scrutiny.Proximal LAD Occlusion with STE in I and aVL, and hyperacute T-waves in V2-V6.Algorithm: Marquette 12 SL (GE)The Queen gets it rightCase 9 (prehospital and ED ECGs). Echocardiography, even (or especially) with Speckle Tracking, can get you in trouble. The ECG told the story. 30 yo woman with trapezius pain. HEART Pathway = 0. Computer " Normal " ECG. Reality: ECG is Diagnostic of LAD Occlusion.Prehospital ECG:There are hyperacute T-waves in V3-V5.The Queen gets it rightFirst ED ECG:Hyperacute T-waves persist. Called normal again! Algorithm: Veritas (on Mortara...
Source: Dr. Smith's ECG Blog - March 4, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs
How will you save this critically ill patient? A fundamental and lifesaving ECG interpretation that everyone must recognize instantly.
Written by Pendell MeyersA woman in her 30s called EMS for acute symptoms including near-syncope, nausea, diaphoresis, and abdominal pain. EMS arrived and found her to appear altered, critically ill, and hypotensive. An ECG was performed:What do you think?Extremely wide complex monomorphic rhythm just over 100 bpm. The QRS is so wide andsinusoidal that the only real possibilities left are hyperkalemia or Na channel blockade. Hyperkalemia is by far more common.Indeed, further history revealed two missed dialysis sessions. And of course on exam she has a dialysis fistula.EMS reportedly gave 4 grams of calcium (unknown w...
Source: Dr. Smith's ECG Blog - February 22, 2024 Category: Cardiology Authors: Pendell Source Type: blogs
